A list of the most recent deficiencies for Willows Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-01 | 2023-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-11 | 2022-11-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-11 | 2022-11-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-13 | 2022-04-27 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-04-07 | 2022-04-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-07 | 2022-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-04-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-07 | 2022-04-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-08 | 2021-12-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-08 | 2021-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-08 | 2021-12-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-04 | 2021-12-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-04 | 2021-12-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-04 | 2021-12-07 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-04 | 2021-12-07 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-04-21 | 2021-06-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-21 | 2021-06-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-21 | 2021-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-21 | 2021-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-21 | 2021-06-16 | N |
| Provide or obtain dental services for each resident. | Health | 2021-04-21 | 2021-06-16 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-04-21 | 2021-06-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-04-21 | 2021-06-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-21 | 2021-06-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-21 | 2021-06-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-21 | 2021-06-16 | N |
| Keep all essential equipment working safely. | Health | 2021-04-21 | 2021-06-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-21 | 2021-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-21 | 2021-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-21 | 2021-06-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-21 | 2021-06-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-21 | 2021-06-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-21 | 2021-06-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-27 | 2021-05-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-27 | 2021-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-27 | 2021-05-14 | N |
